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Barile-Fabris LA, Fragoso-Loyo H, Wojdyla D, Quintana R, Pons-Estel GJ, Catoggio LJ, García MA, Saurit V, Drenkard C, Bonfa E, Borba EF, Sato E, Tavares Brenol JC, Cavalcanti F, Da Silva NA, Lavras Costallat LT, Guibert Toledano M, Massardo L, Neira O, Cardiel MH, Amigo MC, García De La Torre I, Silveira LH, Acevedo Vásquez EM, Chacón-Diaz R, Esteva-Spinetti MH, Alarcón GS, Pons-Estel BA. Factors associated with neuropsychiatric involvement in Latin American patients with systemic lupus erythematosus. Lupus 2021; 30:1481-1491. [PMID: 34082589 DOI: 10.1177/09612033211020364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Factors related to presentation of neuropsychiatric (NP) SLE manifestations, early in the course of the disease, and during follow up have not been clearly established. PURPOSE To identify disease and non-disease related factors associated with NP manifestations in early SLE. METHODS We included 1193 patients from the GLADEL inception cohort free of NP involvement at cohort entry. We evaluated the association of demographic, clinical and laboratory data with NP involvement during follow-up. STATISTICAL METHODS Independent factors associated with NP involvement were identified using a multivariable Cox regression model. RESULTS Factors independently associated with NP manifestations were: mestizo ethnicity (HR 1.701, 95% CI 1.282-2.258, p = 0.0002), myalgias/myositis (HR 1.832, 95% CI 1.335-2.515, p = 0.0002), pneumonitis (HR 2.476, 95% CI 1.085-5.648, p = 0.0312), shrinking lung (HR 2.428, 95% CI 1.074-5.493, p = 0.0331) and hemolytic anemia (HR 1.629, 95% CI 1.130-2.347, p = 0.0089). Longer disease duration at cohort entry (13 to 24 months) was associated with a lower risk of developing NP manifestations (HR 0.642, 95% CI 0.441-0.934, p = 0.0206). CONCLUSIONS Patients with myalgias/myositis, pneumonitis, shrinking lung and hemolytic anemia are at higher risk of NP involvement, whereas longer disease duration at cohort entry is associated with a lower risk of developing NP involvement.
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Affiliation(s)
| | - Hilda Fragoso-Loyo
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Ciudad de México, México
| | | | - Rosana Quintana
- Grupo Oroño - Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Guillermo J Pons-Estel
- Grupo Oroño - Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Luis J Catoggio
- Sección de Reumatología, Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Instituto Universitario Escuela de Medicina y Fundación Dr. Pedro M. Catoggio para el Progreso de la Reumatología, Buenos Aires, Argentina
| | - Mercedes A García
- Servicio de Reumatología, HIGA General San Martín, La Plata, Argentina
| | - Verónica Saurit
- Servicio de Reumatología, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Cristina Drenkard
- Division of Rheumatology, Department of Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Eloisa Bonfa
- Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo SP, Brasil
| | - Eduardo F Borba
- Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo SP, Brasil
| | - Emilia Sato
- Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paul, Brasil
| | - Joao C Tavares Brenol
- Rheumatology Division, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
| | - Fernando Cavalcanti
- Serviço de Reumatologia do Hospital das Clínicas da Universidade Federal de Pernambuco (HC-UFPE), Recife, Brasil
| | - Nilzio A Da Silva
- Serviço de Reumatologia, Departamento de Clinica Medica, Facultad de Medicina, Hospital das Clínicas, Universidade Federal de Goiás, Goiânia, Brasil
| | - Lilian T Lavras Costallat
- Departamento de Clínica Médica, Faculdade de Ciências Medicas da UNICAMP, Universidade Estadual de Campinas, Campinas, Brasil
| | - Marlene Guibert Toledano
- Servicio Nacional de Reumatología, Centro de Investigaciones Médico-Quirúrgicas (CIMEQ), La Habana, Cuba
| | - Loreto Massardo
- Facultad de Medicina y Ciencia, Centro de Biología Celular y Biomedicina, Universidad San Sebastián, Santiago, Chile
| | - Oscar Neira
- Sección de Reumatología, Hospital del Salvador, Universidad de Chile, Unidad de Reumatología, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Mario H Cardiel
- Centro de Investigación Clínica de Morelia, SC, Morelia, México
| | - Mary Carmen Amigo
- Servicio de Reumatología, Centro Médico ABC, Ciudad de México, México
| | | | - Luis H Silveira
- Departamento de Reumatología, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México
| | - Eduardo M Acevedo Vásquez
- Facultad de Medicina, Universidad Nacional Mayor de San Marcos. Servicio de Reumatología. Clínica San Felipe, Jesús María, Lima, Perú
| | - Rosa Chacón-Diaz
- Servicio de Reumatología, Policlínica Méndez Gimón, Caracas, Venezuela
| | | | - Graciela S Alarcón
- Division of Clinical Immunology and Rheumatology, Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano, Heredia, Lima, Perú
| | - Bernardo A Pons-Estel
- Grupo Oroño - Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
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Deijns SJ, Broen JCA, Kruyt ND, Schubart CD, Andreoli L, Tincani A, Limper M. The immunologic etiology of psychiatric manifestations in systemic lupus erythematosus: A narrative review on the role of the blood brain barrier, antibodies, cytokines and chemokines. Autoimmun Rev 2020; 19:102592. [PMID: 32561462 DOI: 10.1016/j.autrev.2020.102592] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The aim of this narrative review is to provide an overview of the literature on the possible immunologic pathophysiology of psychiatric manifestations of neuropsychiatric systemic lupus erythematosus (NPSLE). METHODS A systematic search on PubMed was conducted. English studies with full text availability that investigated the correlation between blood-brain barrier (BBB) dysfunction, intrathecal synthesis of antibodies, antibodies, cytokines, chemokines, metalloproteinases, complement and psychiatric NPSLE manifestations in adults were included. RESULTS Both transient BBB-dysfunction with consequent access of antibodies to the cerebrospinal fluid (CSF) and intrathecal synthesis of antibodies could occur in psychiatric NPSLE. Anti-phospholipid antibodies, anti-NMDA antibodies and anti-ribosomal protein p antibodies seem to mediate concentration dependent neuronal dysfunction. Interferon-α may induce microglial engulfment of neurons, direct neuronal damage and production of cytokines and chemokines in psychiatric NPSLE. Several cytokines, chemokines and matrix metalloproteinase-9 may contribute to the pathophysiology of psychiatric NPSLE by attracting and activating Th1-cells and B-cells. DISCUSSION This potential pathophysiology may help understand NPSLE and may have implications for the diagnostic management and therapy of psychiatric NPSLE. However, the presented pathophysiological model is based on correlations between potential immunologic etiologies and psychiatric NPSLE that remain questionable. More research on this topic is necessary to further elucidate the pathophysiology of NPSLE.
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Affiliation(s)
- Sander J Deijns
- University Medical Centre Utrecht and Utrecht University, Utrecht 3584 CX, the Netherlands
| | - Jasper C A Broen
- Regional Rheumatology Centre, Máxima Medical Centre, 5631 BM Eindhoven and 5504 DB, Veldhoven, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Centre, Leiden 2333 ZA, the Netherlands.
| | - Chris D Schubart
- Department of Psychiatry, Tergooi Ziekenhuis, 1261 AN Blaricum, Hilversum 1213 XZ, the Netherlands.
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili of Brescia, Brescia, BS 25123, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, BS 25123, Italy.
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili of Brescia, Brescia, BS 25123, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, BS 25123, Italy; I.M. Sechenov First Moscow State Medical University, Moscow, Russia.
| | - Maarten Limper
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht University, Utrecht 3584 CX, the Netherlands.
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Audiovestibular Symptoms in Systemic Autoimmune Diseases. J Immunol Res 2018; 2018:5798103. [PMID: 30211232 PMCID: PMC6120292 DOI: 10.1155/2018/5798103] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 06/11/2018] [Accepted: 07/04/2018] [Indexed: 12/16/2022] Open
Abstract
Immune-mediated inner ear disease can be primary, when the autoimmune response is against the inner ear, or secondary. The latter is characterized by the involvement of the ear in the presence of systemic autoimmune conditions. Sensorineural hearing loss is the most common audiovestibular symptom associated with systemic autoimmune diseases, although conductive hearing impairment may also be present. Hearing loss may present in a sudden, slowly, rapidly progressive or fluctuating form, and is mostly bilateral and asymmetric. Hearing loss shows a good response to corticosteroid therapy that may lead to near-complete hearing restoration. Vestibular symptoms, tinnitus, and aural fullness can be found in patients with systemic autoimmune diseases; they often mimic primary inner ear disorders such as Menière's disease and mainly affect both ears simultaneously. Awareness of inner ear involvement in systemic autoimmune diseases is essential for the good response shown to appropriate treatment. However, it is often misdiagnosed due to variable clinical presentation, limited knowledge, sparse evidence, and lack of specific diagnostic tests. The aim of this review is to analyse available evidence, often only reported in the form of case reports due to the rarity of some of these conditions, of the different clinical presentations of audiological and vestibular symptoms in systemic autoimmune diseases.
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Morad CS, Mansour HE, Ibrahim SE, Ahmad KA, Arafa SG. Subclinical neuropsychiatric dysfunctions in female patients with systemic lupus erythematosus. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2018. [DOI: 10.4103/err.err_46_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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de Jesus GR, Rodrigues BC, Lacerda MI, dos Santos FC, de Jesus NR, Klumb EM, Levy RA. Gestational outcomes in patients with neuropsychiatric systemic lupus erythematosus. Lupus 2017; 26:537-542. [DOI: 10.1177/0961203317693929] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This study analyzed maternal and fetal outcomes of pregnancies of neuropsychiatric systemic lupus erythematosus patients followed in a reference unit. This retrospective cohort study included 26 pregnancies of patients seen between 2011 and 2015 included with history and/or active neuropsychiatric systemic lupus erythematosus among 135 pregnancies. Three patients had active neuropsychiatric systemic lupus erythematosus at conception, but only one remained with neurological activity during gestation, characteristically related to the inadvertent suspension of medications. Twenty six percent of the newborns were small for gestational age and 40% of live births were premature, with no neonatal death or early complications of prematurity. Preeclampsia was diagnosed in nine pregnancies, with two cases of early severe form that resulted in intrauterine fetal death. Patients with neuropsychiatric systemic lupus erythematosus had more prematurity and preeclampsia compared to patients without neuropsychiatric disease. However, when concomitant lupus nephritis was excluded, the gestational results of neuropsychiatric systemic lupus erythematosus patients were more favorable.
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Affiliation(s)
- G R de Jesus
- Department of Obstetrics, State University of Rio de Janeiro, Brazil
| | - B C Rodrigues
- Department of Rheumatology, State University of Rio de Janeiro, Brazil
| | - M I Lacerda
- Department of Rheumatology, State University of Rio de Janeiro, Brazil
| | - F C dos Santos
- Department of Obstetrics, State University of Rio de Janeiro, Brazil
| | - NR de Jesus
- Department of Obstetrics, State University of Rio de Janeiro, Brazil
| | - E M Klumb
- Department of Rheumatology, State University of Rio de Janeiro, Brazil
| | - R A Levy
- Department of Rheumatology, State University of Rio de Janeiro, Brazil
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Maalouly G, Ward C, Smayra V, Saliba Y, Aftimos G, Haddad F, Farès N. Fish oil attenuates neurologic severity of antiphospholipid syndrome in a mice experimental model. Nutr Neurosci 2016; 20:563-570. [PMID: 27426873 DOI: 10.1080/1028415x.2016.1206165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Murine experimental models of antiphospholipid syndrome (eAPLS) showed neurologic dysfunction and therapeutic effect of the anticoagulant enoxaparin is well established. Omega-3 fatty acids and curcumin, tested in neuroinflammation and auto-immunity diseases, might be interesting therapeutic candidates. The aim of this study was to evaluate the effects of these candidates on neurologic severity in eAPLS. METHODS One month after immunization of BALB/c mice with beta-2-glycoprotein I, daily treatments were initiated with enoxaparin (1 mg/kg), omega-3 fatty acids (0.5 g/kg), and curcumin (200 mg/kg) for 3 months. RESULTS Mortality was significantly decreased by enoxaparin and omega-3 treatments. Fish oil and curcumin group exhibited the highest mean of swimming behavior in forced swim test in surviving mice. Mice under omega-3 fatty acids or curcumin presented low anxiety-like behavior in the elevated plus-maze test. Cerebral histopathology revealed heavy inflammatory infiltrates in cortical and subcortical regions with vacuolization, swelling, and degeneration of astrocytes in the control group, with aggravation under curcumin; no infiltrate was retrieved in enoxaparin and omega-3 groups. CONCLUSION Our study is the first to demonstrate a potential therapeutic effect of omega-3 fatty acids in eAPLS. Enoxaparin and omega-3 fatty acids combination would be interesting for further investigation.
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Affiliation(s)
- Georges Maalouly
- a Laboratoire de Recherche en Physiologie et Physiopathologie, Pôle Technologie Santé, Faculté de Médecine , Université Saint Joseph , Beirut , Lebanon
| | - Céline Ward
- b Faculté de Médecine , Université Saint Joseph , Beirut , Lebanon
| | - Viviane Smayra
- c Faculté de Médecine, service d'anatomopathologie , Université Saint Joseph , Beirut , Lebanon
| | - Youakim Saliba
- a Laboratoire de Recherche en Physiologie et Physiopathologie, Pôle Technologie Santé, Faculté de Médecine , Université Saint Joseph , Beirut , Lebanon
| | | | - Fadi Haddad
- e Faculté de Médecine, Département de Médecine interne , Université Saint Joseph , Beirut , Lebanon
| | - Nassim Farès
- a Laboratoire de Recherche en Physiologie et Physiopathologie, Pôle Technologie Santé, Faculté de Médecine , Université Saint Joseph , Beirut , Lebanon
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The diagnosis and clinical management of the neuropsychiatric manifestations of lupus. J Autoimmun 2016; 74:41-72. [PMID: 27427403 DOI: 10.1016/j.jaut.2016.06.013] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 06/21/2016] [Indexed: 01/03/2023]
Abstract
Neuropsychiatric (NP) involvement in Systemic Lupus Erythematosus (SLE), can be a severe and troubling manifestation of the disease that heavily impacts patient's health, quality of life and disease outcome. It is one of the most complex expressions of SLE which can affect central, peripheral and autonomous nervous system. Complex interrelated pathogenetic mechanisms, including genetic factors, vasculopathy, vascular occlusion, neuroendocrine-immune imbalance, tissue and neuronal damage mediated by autoantibodies, inflammatory mediators, blood brain barrier dysfunction and direct neuronal cell death can be all involved. About NPSLE a number of issues are still matter of debate: from classification and burden of NPSLE to attribution and diagnosis. The role of neuroimaging and new methods of investigation still remain pivotal and rapidly evolving as well as is the increasing knowledge in the pathogenesis. Overall, two main pathogenetic pathways have been recognized yielding different clinical phenotypes: a predominant ischemic-vascular one involving large and small blood vessels, mediated by aPL, immune complexes and leuko-agglutination which it is manifested with more frequent focal NP clinical pictures and a predominantly inflammatory-neurotoxic one mediated by complement activation, increased permeability of the BBB, intrathecal migration of autoantibodies, local production of immune complexes and pro-inflammatory cytokines and other inflammatory mediators usually appearing as diffuse NP manifestations. In the attempt to depict a journey throughout NPSLE from diagnosis to a reasoned therapeutic approach, classification, epidemiology, attribution, risk factors, diagnostic challenges, neuroimaging techniques and pathogenesis will be considered in this narrative review based on the most relevant and recent published data.
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Noureldine MHA, Harifi G, Berjawi A, Haydar AA, Nader M, Elnawar R, Sweid A, Al Saleh J, Khamashta MA, Uthman I. Hughes syndrome and epilepsy: when to test for antiphospholipid antibodies? Lupus 2016; 25:1397-1411. [DOI: 10.1177/0961203316651747] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Epilepsy and seizures are reported among the neurological manifestations of antiphospholipid syndrome (APS) at a prevalence rate of approximately 8%, which is nearly 10 times the prevalence of epilepsy in the general population. The association of seizures with antiphospholipid antibodies (aPL) is even more significant in the presence of systemic lupus erythematosus (SLE). In this review, we discuss the epidemiological, pathophysiological, laboratory, clinical, and radiological aspects of this association, and derive suggestions on when to consider testing for aPL in epileptic patients and how to manage seizures secondary to APS based on literature data. Epilepsy due to APS should be considered in young patients presenting with seizures of unknown origin. Temporal lobe epilepsy seems to be particularly prevalent in APS patients. The pathogenesis is complex and may not only involve micro-thrombosis, but also a possible immune-mediated neuronal damage. Patients with seizures and positive aPL tend to develop thrombocytopenia and livedo racemosa more frequently compared with those without aPL. Magnetic resonance imaging (MRI) remains the imaging modality of choice in these patients. The presence of SLE and the presence of neurological symptoms significantly correlate with the presence of white matter changes on MRI. In contrast, the correlation between aPL positivity and the presence of white matter changes is very weak. Furthermore, MRI can be normal in more than 30–40% of neuropsychiatric lupus patients with or without aPL. aPL testing is recommended in young patients presenting with atypical seizures and multiple hyper-intensity lesions on brain MRI in the absence of other possible conditions. New MRI techniques can better understand the pathology of brain damage in neuro-APS. The therapeutic management of epileptic APS patients relies on anti-epileptic treatment and anticoagulant agents when there is evidence of a thrombotic event. In the absence of consensual recommendations, the decision of lifelong anticoagulation is discussed on a case-by-case basis. The anti-thrombotic benefit of hydroxychloroquine and statins is supported by several studies.
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Affiliation(s)
- M H A Noureldine
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University Medical Center, Beirut, Lebanon
| | - G Harifi
- Department of Rheumatology, Dubai Hospital, Dubai, UAE
| | - A Berjawi
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University Medical Center, Beirut, Lebanon
| | - A A Haydar
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University Medical Center, Beirut, Lebanon
| | - M Nader
- Department of Neurology, Lebanese American University Medical Center, Beirut, Lebanon
| | - R Elnawar
- Département de Neurologie, Université Paris Diderot, Paris, France
| | - A Sweid
- Department of Neurosurgery, Lebanese American University Medical Center, Beirut, Lebanon
| | - J Al Saleh
- Department of Rheumatology, Dubai Hospital, Dubai, UAE
| | - M A Khamashta
- Department of Rheumatology, Dubai Hospital, Dubai, UAE
- Division of Women’s Health, St Thomas’s Hospital, London, UK
| | - I Uthman
- Division of Rheumatology, American University of Beirut, Beirut, Lebanon
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Cimaz R, Meroni PL, Shoenfeld Y. Epilepsy as part of systemic lupus erythematosus and systemic antiphospholipid syndrome (Hughes syndrome). Lupus 2016; 15:191-7. [PMID: 16686257 DOI: 10.1191/0961203306lu2272rr] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The antiphospholipid syndrome (APS) is defined by the presence of antiphospholipid antibodies (aPL), demonstrated by ELISAs for antibodies against phospholipids and associated phospholipid-binding cofactor proteins and/or a circulating lupus anticoagulant (LA) together with diverse systemic clinical manifestations such as thrombosis, and recurrent spontaneous abortions. According to the criteria set out in Sydney1 the only neurological manifestations that can be suitable as APS classification criteria are ischemic events (stroke and transient ischemic attacks). However, other neurological manifestations, including seizures in particular, have been repeatedly reported in APS patients.2 The present review will summarize recent research on the association of aPL, as well as other autoantibodies, with seizure disorders, with or without concomitant SLE.
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Affiliation(s)
- R Cimaz
- Department de Pédiatrie, Hôpital Herriot, and Universitè Claude Bernard Lyon 1, France.
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Morelli S, Bernardo ML, Viganego F, Sgreccia A, De Marzio P, Conti F, Priori R, Valesini G. Left-sided heart valve abnormalities and risk of ischemic cerebrovascular accidents in patients with systemic lupus erythematosus. Lupus 2016; 12:805-12. [PMID: 14667095 DOI: 10.1191/0961203303lu468oa] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of the study was to assess the relationship between ischemic cerebrovascular accidents (ICVAs), that is, transient ischemic attack (TIA) or stroke, and left-sided heart valve abnormalities (LHVAs) in patients with systemic lupus erythematosus (SLE). In total, 71 consecutive SLE patients were studied.At baseline, history, clinical and laboratoryevaluations, as well as trans-thoracic echocardiography (TTE) were performed. From the original population, so patients were followed up for a mean time of 5.80 + 1.53 years. After a mean period of 5.39 + 1.42 years; 40 patients underwent a repeat TTE. Previous ICVA history was present at baseline in 16 patients (22.5%). Of these, 13 (81.2%) had evidence of LHVAs on TTE. Previous ICVAs were significantly associated to diagnosis of secondary anti-phospholipid syndrome (SAPS), positivity for anti-cardiolipin antibodies (aCl), and LHVAs. Multivariate analysis confirmed the correlation between previous ICVAs and LHVAs. LHVAs were not more commonly observed in patients with SAPS compared to patients without SAPS. At the end of follow-up, irrespective of any differences in antithrombotic treatment, ICVAs had occurred in 13 patients.During follow-up, ICVAs had recurredin seven patients, while a first eventTIA occurredin one patient. Multivariate analysis confirmed the relationship between ICVAs and LHVAs, and a trend towards a positive correlation of the former with SAPS. This study demonstratesthat LHVAs represent a compelling risk factor for the development of ICVAs in SLE patients. Conversely, SAPS and aCl positivity, although associated with ICVAs, did not clearly correlate with LHVAs in our study. These results provide insight on the pathogenesis of ICVAs and may give clues on the potential efficacy of preventive/therapeutic strategies in different SLE subpopulations.
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Affiliation(s)
- S Morelli
- Dipartimento di Medicina Intema, Policlinico Umberto I, University of Rome 'La Sapienza', Rome, Italy.
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Weide R, Heymanns J, Pandorf A, Köppler H. Successful long-term treatment of systemic lupus erythematosus with rituximab maintenance therapy. Lupus 2016; 12:779-82. [PMID: 14596428 DOI: 10.1191/0961203303lu449cr] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Systemic lupus erythematosus(SLE) is a chronic, inflammatory autoimmune disease that may involve multiple organ systems. Treatment consists of immunosuppression, cytotoxic treatment, plasmapheresis and immunoglobuline therapy. Treatment of patients refractory to standard treatment approaches is difficult and results are poor. We describe a 39-year old patient with SLE sufferingfrom grand mal epilepsy due to cerebralvasculopathywith positivelupus anticoagulant, who was refractory to standard treatment modalities. The patient was treated with the anti-CD20 monoclonal antibody rituximab (375 mg/m2 ×4, repeated at weekly intervals). Rituximab applications were delivered in October 2000, March 2001 and October 2001. Since March 2002 she has received maintenance therapy with rituximab 375 mg/m2 every three months. A second female with refractory SLE was treated successfully in April 2002 and receives maintenance therapy every three months. Both patients responded well to rituximab therapy. The first patient showed a major improvement of her clinical condition, and 30 months after the beginning of the rituximab therapy she is free of any symptoms. inflammation parameters, ANA and lupus anticoagulantdeclined significantly after the treatment. The clinical conditionof the second patient improved dramatically, all inflammation parameters normalized and her circulating immunocomplexes disappeared. In conclusion, rituximab maintenance treatment may be a new effective therapy in SLE.
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Affiliation(s)
- R Weide
- Haematology/Oncology Group Practice, Koblenz, Germany.
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Abstract
Management of central nervous system (CNS) involvement still remains one of the most challenging problems in systemic lupus erythematosus (SLE). The best available evidence for the treatment of CNS lupus is largely based on retrospectiveseries, case reports and expert opinion. Current therapy is empirical and tailored to the individual patient. Symptomatic, immunosuppressiveand anticoagulant therapies are the main strategies for the management of CNS lupus. The choice depends on the most probable underlying pathogenic mechanism and the severity of the presenting neuropsychiatric symptoms. Thrombotic and nonthrombotic CNS disease needs to be differentiated and requires different management strategies. However, this is often challenging since many, if not most CNS manifestations, may be due to a combination of different pathogenic mechanisms and multiple CNS events may occur in the individual patient. Patients with mild manifestations may need symptomatic treatment only, whereas more severe acute nonthrombotic CNS manifestations may require pulse intravenouscyclophosphamide.Plasmapheresismay also be added in patients with more severe illness refractory to conventionaltreatment. Recently, the use of intrathecalmethotrexateand dexamethasone has been reported in a small series of patients, with a good outcome in patients with severe CNS manifestations.Anticoagulationis warranted in patients with thrombotic disease, particularlyin those with the antiphospholipid syndrome (APS). This article reviews the clinical approach to therapy in patients with CNS lupus.
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Affiliation(s)
- G Sanna
- Department of Rheumatology, Homerton University Hospital, London E9 6SR, UK.
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Touma Z, Atweh SF, Kibbi L, Arayssi T. Longitudinal myelitis in patient with systemic lupus erythematosus, homozygous prothrombin G20210A and heterozygous MTHFR 677T. Lupus 2016; 16:517-20. [PMID: 17670851 DOI: 10.1177/0961203307077830] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Longitudinal myelitis is an uncommon complication of systemic lupus erythematosus (SLE). We describe an unusual case of longitudinal myelitis and ischemic stroke in the presence of homozygous prothrombin G20210A, heterozygous MTHFR 677T mutations and the absence of antiphospholipid antibodies in a young woman with SLE. Lupus (2007) 16, 517—520.
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Affiliation(s)
- Z Touma
- Department of Internal Medicine, Division of Rheumatology, American University of Beirut Medical Center, New York, NY 10017-2303, USA
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Parvez K, Al-Arfaj ARS, Hamdani MA, Naseeb F, Daif A, Hussain S. Pattern of MRI brain in neuro-psychiatric SLE. Effect of anti-phospholipid antibodies: A study at a tertiary care teaching hospital. Pak J Med Sci 2015; 31:1182-7. [PMID: 26649010 PMCID: PMC4641279 DOI: 10.12669/pjms.315.7975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To compare the neuro-radiologic findings in Systemic lupus erythematosus (SLE) patients with and without antiphospholipid antibodies (aPL) in different neuro-psychiatric manifestations. METHODS This cross-sectional comparative study was carried out at King Khalid University Hospital, a tertiary care teaching hospital, Riyadh, Saudi Arabia from June 2012 to January 2015. Ninety seven SLE patients with neuro-psychiatric manifestations were included in the study and divided into two groups. Group I (50 patients) SLE with aPL and group II (47 patients) SLE without aPL. We compared Demographic features, clinical manifestations and magnetic resonance imaging (MRI) brain findings. RESULTS Demographic and clinical characteristics of two groups were similar. In Group-I, anticardiolipin antibodies (aCL) were most common (86%). In patients with headache, most of the patients in Group-I had white matter hyperintensities (WMHIs) (50% vs 27%) while most of the patients in Group-II had normal MRI brain (38% vs 73%). Similarly WMHIs were found more in Group-I patients with seizures (60% vs 21%), while ischemia/infarction, atrophy and normal MRI were found in Group-II. MRI brain in patients with neurological deficit and psychiatric disorder were not much different in both the groups. CONCLUSION We found no statistically significant differences in frequencies of MRI brain abnormalities in SLE patients with and without aPL antibodies. Each of the three aPL may have a variable effect on the brain.
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Affiliation(s)
- Khalid Parvez
- Khalid Parvez, FCPS, MRCP. Registrar, Division of Rheumatology, Department of Medicine, King Khalid University Hospital (KKUH), King Saud University (KSU), Riyadh, Saudi Arabia
| | - Abdul Rahman Saud Al-Arfaj
- Abdul Rahman Saud Al-Arfaj, MRCP, FRCPC, ABIM, Professor of Rheumatology, Department of Medicine, King Khalid University Hospital (KKUH), King Saud University (KSU), Riyadh, Saudi Arabia
| | - Muhammad Afzal Hamdani
- Muhammad Afzal Hamdani, FCPS, Dip-Card., MRCP. Senior Registrar, Division of Rheumatology, Department of Medicine, King Khalid University Hospital (KKUH), King Saud University (KSU), Riyadh, Saudi Arabia
| | - Faisal Naseeb
- Faisal Naseeb, FCPS, MRCP. Registrar, Division of Rheumatology, Department of Medicine, King Khalid University Hospital (KKUH), King Saud University (KSU), Riyadh, Saudi Arabia
| | - Abdulkader Daif
- Dr. Abdulkader Daif, MD. Professor of Neurology, Department of Medicine, King Khalid University Hospital (KKUH), King Saud University (KSU), Riyadh, Saudi Arabia
| | - Sajjad Hussain
- Sajjad Hussain MD. Assistant Professor and Consultant Neuro-radiologist, Department of Radiology, King Khalid University Hospital (KKUH), King Saud University (KSU), Riyadh, Saudi Arabia
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Ho RC, Thiaghu C, Ong H, Lu Y, Ho CS, Tam WW, Zhang MW. A meta-analysis of serum and cerebrospinal fluid autoantibodies in neuropsychiatric systemic lupus erythematosus. Autoimmun Rev 2015; 15:124-38. [PMID: 26497108 DOI: 10.1016/j.autrev.2015.10.003] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/14/2015] [Indexed: 12/22/2022]
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) is one of the most devastating presentations of SLE and comprises of psychiatric, central and peripheral neurological signs and symptoms. Previous studies suggest the possible associations between various autoantibodies (Abs) and NPSLE. The magnitudes of such association varied between studies. We performed a meta-analysis to pool data on serum and cerebrospinal fluid (CSF) levels and positivity of Abs in blood and cerebrospinal fluid in patients with NPSLE and SLE. A systematic literature search was conducted to identify studies that fulfilled inclusion criteria. A random-effects model was used to calculate overall combined odd ratio (OR) and mean levels with its corresponding 95% confidence interval to evaluate the relationship between individual Abs and NPSLE patients relative to SLE patients. Forty-one studies met the inclusion criteria and were used in this analysis. There was a significantly greater proportion of NPSLE patients who demonstrated positivity for serum anti-cardiolipin (aCL) Abs (OR=1.63, p=0.016), lupus anticoagulants (LA) Abs (OR=1.91 p=0.01), anti-phospholipid (APL) Abs (OR=2.08, p=0.001), anti-ribosomal P Abs (OR=2.29, p<0.001), anti-neuronal Abs (OR=9.50, p<0.001) as compared to SLE patients. In NPSLE patients, there was a significant increased prevalence of positive titres for CSF anti-neuronal Abs (OR=36.84, p=0.001) as compared to SLE patients. Among the 19 neuropsychiatric syndromes, the positivity of these serum autoantibodies were found specifically significantly associated with the manifestations of mood disorder, psychosis, cerebrovascular disease, seizure disorders, acute confusional state, cognitive dysfunction, headache, movement disorder, demyelinating syndrome and polyneuropathy, with ORs ranging from 1.84 to 4.73. Meta-regression identified proportion of women as significant moderator for the heterogeneity of aCL (p=0.004) and anti-neuronal Abs (p=0.0007); mean age for the heterogeneity of aCL (p=0.042) and LA (p=0.020) Abs, mean duration of illness for the heterogeneity of aCL Abs (p=0.035), and mean SLEDAI scores for the heterogeneity of anti-ribosomal P Abs (p=0.014). NPSLE patients are more likely to have elevated serum levels of aCL, LA, APL, anti-ribosomal P Abs and anti-neuronal Abs compared with SLE patients. Further research is required to evaluate the accuracy of using the above antibodies as an adjunct diagnostic tool in NPSLE.
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Affiliation(s)
- Roger C Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - C Thiaghu
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Huiyi Ong
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yanxia Lu
- Department of Clinical Psychology and Psychiatry/School of Public Health, Zhejiang University College of Medicine, Hangzhou, China.
| | - Cyrus S Ho
- Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wilson W Tam
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Katikaneni M, Gangam M, Berney SM, Umer S. Antiphospholipid Syndrome (APS) - An Update on Clinical Features and Treatment Options. ACTA ACUST UNITED AC 2015. [DOI: 10.2174/1874303x01508020027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoantibody disorder characterized by the presence of antiphospholipid (APL) antibodies and heterogeneous clinical manifestations. Patients may present with recurrent thrombosis, obstetric morbidity, cardiac valvular lesions, thrombocytopenia, skin lesions, renal or neurologic abnormalities. We provide a comprehensive review of these diverse clinical features except renal and obstetric complications. Treatment of APS can be challenging as one tries to balance the benefit of anticoagulation therapy in this hypercoagulable state while minimizing the risk of bleeding. We discuss the various therapeutic options including the role of aspirin, warfarin, low molecular weight heparin, new direct thrombin inhibitors, hydroxychloroquine, intravenous gamma globulin, rituximab and others. Lower risk APS patients (i.e. first venous thrombosis) should receive warfarin with a target INR of 2.0-3.0. Higher risk patients (i.e. arterial thrombosis or recurrent venous events) have a target INR of >3.0. Currently, warfarin remains the mainstay in treatment of APS. Because of lack of adequate data, the newer oral direct inhibitors should be considered only when there is a known allergy/ intolerance or poor control with warfarin. Additional vascular and thrombotic risk factors should be aggressively reduced. Further studies involving large number of APS patients, diagnosed according to accepted criteria, are needed to better define the role of newer anticoagulants and other novel therapies.
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Abreu MM, Danowski A, Wahl DG, Amigo MC, Tektonidou M, Pacheco MS, Fleming N, Domingues V, Sciascia S, Lyra JO, Petri M, Khamashta M, Levy RA. The relevance of "non-criteria" clinical manifestations of antiphospholipid syndrome: 14th International Congress on Antiphospholipid Antibodies Technical Task Force Report on Antiphospholipid Syndrome Clinical Features. Autoimmun Rev 2015; 14:401-14. [PMID: 25641203 DOI: 10.1016/j.autrev.2015.01.002] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 01/05/2015] [Indexed: 12/21/2022]
Abstract
The purpose of this task force was to critically analyze nine non-criteria manifestations of APS to support their inclusion as APS classification criteria. The Task Force Members selected the non-criteria clinical manifestations according to their clinical relevance, that is, the patient-important outcome from clinician perspective. They included superficial vein thrombosis, thrombocytopenia, renal microangiopathy, heart valve disease, livedo reticularis, migraine, chorea, seizures and myelitis, which were reviewed by this International Task Force collaboration, in addition to the seronegative APS (SN-APS). GRADE system was used to evaluate the quality of evidence of medical literature of each selected item. This critical appraisal exercise aimed to support the debate regarding the clinical picture of APS. We found that the overall GRADE analysis was very low for migraine and seizures, low for superficial venous thrombosis, thrombocytopenia, chorea, longitudinal myelitis and the so-called seronegative APS and moderate for APS nephropathy, heart valve lesions and livedo reticularis. The next step can be a critical redefinition of an APS gold standard, for instance derived from the APS ACTION registry that will include not only current APS patients but also those with antiphospholipid antibodies not meeting current classification criteria.
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Affiliation(s)
- Mirhelen M Abreu
- Disciplina de Reumatologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Adriana Danowski
- Serviço de Reumatologia, Hospital do Servidor Estadual do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Denis G Wahl
- Vascular Medicine Division and Regional Competence Centre For Rare Vascular and Systemic Autoimmune Diseases, Centre Hospitalier Universitaire (CHU), Nancy, France; Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, Vandoeuvre-les-Nancy, France; Institut National de la Santé et de la Recherche Médicale (INSERM), U1116, Vandoeuvre-les-Nancy Cedex, France
| | | | - Maria Tektonidou
- First Department of Internal Medicine, University of Athens, Athens, Greece
| | - Marcelo S Pacheco
- Serviço de Reumatologia, Hospital do Servidor Estadual do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Norma Fleming
- Pedro Ernesto University Hospital of the Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vinicius Domingues
- New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Savino Sciascia
- Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare and Università di Torino, Dipartimento di Scienze Cliniche e Biologiche, Torino, Italy; Graham Hughes Lupus Research Laboratory, King's College London, London, UK
| | - Julia O Lyra
- Rio de Janeiro Municipality, Rio de Janeiro, Brazil
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Roger A Levy
- Discipline of Rheumatology, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
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Yoshio T, Okamoto H. Pathogenesis of Neuropsychiatric Syndromes of Systemic Lupus Erythematosus. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/ojra.2015.52009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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20
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Affiliation(s)
- John W Eikelboom
- From the Departments of Medicine (J.W.E., J.I.W.) and Biochemistry and Biomedical Sciences (J.I.W.), the Population Health Research Institute (J.W.E.), and the Thrombosis and Atherosclerosis Research Institute (J.W.E., J.I.W.), McMaster University, Hamilton, ON, Canada
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21
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El-Zorkany BK, Mahmoud GA, Shahin HA, Moustafa H, Shahin AA. Tumor necrosis factor-alpha and neuropsychiatric lupus erythematosus: relation to single photon emission computed tomography findings. Mod Rheumatol 2014; 13:250-5. [PMID: 24387213 DOI: 10.3109/s10165-003-0231-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract This study was designed to highlight the relation of tumor necrosis factor-α (TNF-α) to neuropsychiatric lupus (NPLE) manifestations. The relation of TNF-α to the type of single photon emission computed tomography (SPECT) findings in this context was also studied. Twenty-one systemic lupus erythematosus (SLE) females, mean age 27.57 ± 9.89 years, and twenty age-matched normal females (controls), were subjected to TNF-α assessment. Different clinical and neuropsychiatric manifestations were evaluated. SPECT was carried out for all patients. The results showed that the mean TNF-α level (pg/ml) was significantly raised in patients compared with controls (167.8 ± 102.5 versus 64 ± 50.2, respectively, P < 0.005). Thirteen patients (69.1%) had NPLE manifestations. NPLE patients had a significantly higher mean TNF-α than patients without NPLE (203 ± 102.8 versus 109 ± 47.3, respectively, P < 0.03). Positive SPECT findings were found in 18 lupus patients (85.7%), including all 13 patients with NPLE (100% sensitivity), with a multiple focal pattern of hypoperfusion being the most frequent type (9/13), followed by diffuse (3/13), and then single focal pattern (1/13). The mean TNF-α was significantly higher in patients with multiple focal pattern (P < 0.001). In conclusion, results of this work support the hypothesis that TNF-α could be involved in the pathogenesis of NPLE, and hence, it could be speculated that the evolving anti-TNF therapy can play a potential role in the management of this disease.
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Affiliation(s)
- Bassel K El-Zorkany
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, Cairo University , Cairo , Egypt
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Arinuma Y, Kikuchi H, Aramaki K, Kyogoku M, Hirohata S. Histopathological analysis of cerebral hemorrhage in systemic lupus erythematosus complicated with antiphospholipid syndrome. Mod Rheumatol 2014. [DOI: 10.3109/s10165-011-0420-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Yoshiyuki Arinuma
- Department of Rheumatology, National Hospital Organization Sagamihara National Hospital,
Sagamihara, Kanagawa 252-0392, Japan
| | - Hirotoshi Kikuchi
- Department of Internal Medicine, Teikyo University School of Medicine,
Tokyo 173-8605, Japan
| | - Kaori Aramaki
- Department of Internal Medicine, Teikyo University School of Medicine,
Tokyo 173-8605, Japan
| | - Masahisa Kyogoku
- Department of Pathology, Tohoku University School of Medicine,
Sendai, Miyagi 980-8575, Japan
| | - Shunsei Hirohata
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine,
1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan
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Toyota T, Akamatsu N, Tanaka A, Shouzaki T, Tsuji S, Saito K, Tanaka Y. Mesial temporal lobe epilepsy as a neuropsychiatric syndrome of systemic lupus erythematosus. Epilepsia 2012; 54:e33-6. [PMID: 23126460 DOI: 10.1111/epi.12012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In this study, we aimed to investigate the types of seizures and epilepsy associated with systemic lupus erythematosus (SLE). We searched the medical records at a tertiary referral center to identify a cohort of epilepsy patients with SLE who were treated between January 2000 and August 2011. We analyzed the clinical and immunologic profiles of these patients, their seizure and epilepsy classifications, electroencephalography (EEG) and magnetic resonance imaging (MRI) assessments, and the treatment administered for epilepsy and SLE. As the result, 17 patients with SLE and epilepsy were identified. Seven patients had mesial temporal lobe epilepsy (MTLE), eight had epilepsy secondary to stroke, and two had generalized epilepsy. Of the seven patients with MTLE, anteriotemporal spikes were noted in all patients with EEG, and MRI findings suggesting hippocampal sclerosis were noted in four patients. Clobazam and levetiracetam were effective in treating three patients, and one patient underwent amygdalohippocampectomy. In conclusion, MTLE may be a characteristic manifestation of neuropsychiatric syndrome of systemic lupus erythematosus.
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Affiliation(s)
- Tomoko Toyota
- Department of Neurology, University of Occupational and Environmental Health School of Medicine, Kitakyushu, Japan
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Popescu A, Kao AH. Neuropsychiatric systemic lupus erythematosus. Curr Neuropharmacol 2012; 9:449-57. [PMID: 22379459 PMCID: PMC3151599 DOI: 10.2174/157015911796557984] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Revised: 08/24/2010] [Accepted: 08/25/2010] [Indexed: 02/06/2023] Open
Abstract
Neuropsychiatric systemic lupus erythematosus (NPSLE) is the least understood, yet perhaps the most prevalent manifestation of lupus. The pathogenesis of NPSLE is multifactorial and involves various inflammatory cytokines, autoantibodies, and immune complexes resulting in vasculopathic, cytotoxic and autoantibody-mediated neuronal injury. The management of NPSLE is multimodal and has not been subjected to rigorous study. Different treatment regimens include nonsteroidal anti-inflammatory drugs, anticoagulation, and immunosuppressives such as cyclophosphamide, azathioprine, mycophenolate mofetil, and methotrexate. For refractory NPSLE, intravenous immunoglobulin (IVIG), plasmapheresis, and rituximab have been used. Adjunctive symptomatic treatment complements these therapies by targeting mood disorders, psychosis, cognitive impairment, seizures or headaches. Several new biological agents are being tested including Belimumab, a human monoclonal antibody that targets B lymphocyte stimulator. This review focuses on the pathophysiology, treatment, and new potential therapies for neuropsychiatric manifestations of systemic lupus erythematosus.
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Affiliation(s)
- Alexandra Popescu
- Department of Neurology, Epilepsy Division, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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25
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Albishri JA. Chorea as a first manifestation in young patients with systemic lupus erythematosus who was initially diagnosed with rheumatic Fever. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2012; 5:19-21. [PMID: 22408372 PMCID: PMC3296492 DOI: 10.4137/ccrep.s9143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Chorea is a rare manifestation of systemic lupus erythematosus (SLE). We report on a young patient with chorea who was diagnosed initially with rheumatic fever. Follow up and further evaluation confirmed the diagnosis of SLE and anti-phospholipid syndrome. Of special interest were the negative antiphospholipid (aPL) antibodies and the initial diagnosis of rheumatic fever which is still not uncommon problem in our region. The rarity of such presentation with joint and non specific increase of antistreptolysin O (ASO) titer might be the factors that led to an incorrect diagnosis. Early diagnosis and treatment of SLE and anti-phospholipid syndrome are very crucial and should be considered with such presentation.
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Affiliation(s)
- Jamal A Albishri
- Internal Medicine Department, Taif University Consultant Rheumatology, Al Hada Hospital, P.O BOX 11135, 21944, KSA
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26
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Hanly JG, Urowitz MB, Su L, Bae SC, Gordon C, Clarke A, Bernatsky S, Vasudevan A, Isenberg D, Rahman A, Wallace DJ, Fortin PR, Gladman D, Romero-Diaz J, Romero-Dirz J, Sanchez-Guerrero J, Dooley MA, Bruce I, Steinsson K, Khamashta M, Manzi S, Ramsey-Goldman R, Sturfelt G, Nived O, van Vollenhoven R, Ramos-Casals M, Aranow C, Mackay M, Kalunian K, Alarcón GS, Fessler BJ, Ruiz-Irastorza G, Petri M, Lim S, Kamen D, Peschken C, Farewell V, Thompson K, Theriault C, Merrill JT. Autoantibodies as biomarkers for the prediction of neuropsychiatric events in systemic lupus erythematosus. Ann Rheum Dis 2011; 70:1726-32. [PMID: 21893582 PMCID: PMC4664555 DOI: 10.1136/ard.2010.148502] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Neuropsychiatric events occur unpredictably in systemic lupus erythematosus (SLE) and most biomarker associations remain to be prospectively validated. This study examined a disease inception cohort of 1047 SLE patients to determine which autoantibodies at enrolment predicted subsequent neuropsychiatric events. METHODS Patients with a recent SLE diagnosis were assessed prospectively for up to 10 years for neuropsychiatric events using the American College of Rheumatology case definitions. Decision rules of graded stringency determined whether neuropsychiatric events were attributable to SLE. Associations between the first neuropsychiatric event and baseline autoantibodies (lupus anticoagulant (LA), anticardiolipin, anti-β(2) glycoprotein-I, anti-ribosomal P and anti-NR2 glutamate receptor) were tested by Cox proportional hazards regression. RESULTS Disease duration at enrolment was 5.4 ± 4.2 months, follow-up was 3.6 ± 2.6 years. Patients were 89.1% female with mean (±SD) age 35.2 ± 13.7 years. 495/1047 (47.3%) developed one or more neuropsychiatric event (total 917 events). Neuropsychiatric events attributed to SLE were 15.4% (model A) and 28.2% (model B). At enrolment 21.9% of patients had LA, 13.4% anticardiolipin, 15.1% anti-β(2) glycoprotein-I, 9.2% anti-ribosomal P and 13.7% anti-NR2 antibodies. LA at baseline was associated with subsequent intracranial thrombosis (total n=22) attributed to SLE (model B) (HR 2.54, 95% CI 1.08 to 5.94). Anti-ribosomal P antibody was associated with subsequent psychosis (total n=14) attributed to SLE (model B) (HR 3.92, 95% CI 1.23 to 12.5, p=0.02). Other autoantibodies did not predict neuropsychiatric events. CONCLUSION In a prospective study of 1047 recently diagnosed SLE patients, LA and anti-ribosomal P antibodies are associated with an increased future risk of intracranial thrombosis and lupus psychosis, respectively.
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Affiliation(s)
- J G Hanly
- Department of Medicine, Division of Rheumatology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
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Predictors for neuropsychiatric development in Chinese adolescents with systemic lupus erythematosus. Rheumatol Int 2011; 32:2681-6. [DOI: 10.1007/s00296-011-2042-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Accepted: 07/10/2011] [Indexed: 10/18/2022]
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28
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Hopia L, Thangarajh M, Khademi M, Laveskog A, Wallström E, Svenungsson E, Andersson M. Cerebrospinal fluid levels of a proliferation-inducing ligand (APRIL) are increased in patients with neuropsychiatric systemic lupus erythematosus. Scand J Rheumatol 2011; 40:363-72. [DOI: 10.3109/03009742.2010.550900] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Arinuma Y, Kikuchi H, Aramaki K, Kyogoku M, Hirohata S. Histopathological analysis of cerebral hemorrhage in systemic lupus erythematosus complicated with antiphospholipid syndrome. Mod Rheumatol 2011; 21:509-13. [PMID: 21318307 DOI: 10.1007/s10165-011-0420-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 01/17/2011] [Indexed: 11/24/2022]
Abstract
A 53-year-old woman was admitted due to akinetic mutism and fever. On admission, brain computed tomography (CT) scan revealed a large hemorrhagic lesion in the left anterior lobe that required surgical operation for total removal. Her neuropsychiatric manifestation was not attenuated after the operation, and was gradually ameliorated by high doses of corticosteroid thereafter, suggesting a diagnosis of lupus psychosis. Histopathological examination revealed a necrotizing vasculature, sometimes with a disrupted lamina elastica interna, completely filled with thrombi and infiltrated with inflammatory cells and their debris. It is therefore suggested that the large frontal lobe hematoma in our patient was induced by thrombosis and arteritis in the subarachnoid space.
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Affiliation(s)
- Yoshiyuki Arinuma
- Department of Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Kanagawa, 252-0392, Japan
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30
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Nicolosi G, Donia MG, Tripi E, Rinollo C. Disturbo psichiatrico e LES: un grave crimine LES correlato. ITALIAN JOURNAL OF MEDICINE 2010. [DOI: 10.1016/j.itjm.2010.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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31
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Bertsias GK, Boumpas DT. Pathogenesis, diagnosis and management of neuropsychiatric SLE manifestations. Nat Rev Rheumatol 2010; 6:358-67. [PMID: 20458332 DOI: 10.1038/nrrheum.2010.62] [Citation(s) in RCA: 184] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Neuropsychiatric events are common in patients with systemic lupus erythematosus (SLE), but less than one-third of these events can be directly attributed to SLE. Increased generalized SLE disease activity or damage, previous or concurrent major neuropsychiatric SLE (NPSLE) events, and persistently positive moderate-to-high antiphospholipid antibody titers are established risk factors, and their presence could facilitate proper attribution to the disease itself. Diagnostic evaluation is guided by the presenting manifestation; MRI is used to visualize brain or spinal pathologies. For neuropsychiatric events believed to reflect an immune or inflammatory process, or when these events occur in the context of active generalized disease, evidence (primarily from uncontrolled studies) supports the use of glucocorticoids alone or in combination with immunosuppressive therapy. Antiplatelet and/or anticoagulation therapy is recommended for NPSLE manifestations related to antiphospholipid antibodies, especially for thrombotic cerebrovascular disease. For the future, we anticipate that novel biomarkers and advanced neuroimaging tests will better define the underlying pathologic mechanisms of SLE-related neuropsychiatric disease, and help guide therapeutic decisions.
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Affiliation(s)
- George K Bertsias
- Division of Rheumatology, Clinical Immunology, and Allergy, Department of Internal Medicine, University of Crete School of Medicine, 1 Voutes Street, 71 003 Heraklion, Greece
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Specchio N, Fusco L, Claps D, Vigevano F. Epileptic encephalopathy in children possibly related to immune-mediated pathogenesis. Brain Dev 2010; 32:51-6. [PMID: 19850427 DOI: 10.1016/j.braindev.2009.09.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Revised: 06/12/2009] [Accepted: 09/09/2009] [Indexed: 11/27/2022]
Abstract
Severe epilepsy in the paediatric population negatively influences neurological and cognitive development. Different etiological factors could be responsible of these severe epilepsies, and an early diagnosis could change, in some cases, the neurological and cognitive development. Immune mechanisms have been reported in epilepsy. Epilepsy has been associated with systemic lupus erythematosus, with the presence of anti-phospholipid antibodies (aPL), anti-cardiolipin antibodies, anti-nuclear antibodies, Beta2-glycoprotein antibodies, and anti-glutamic acid decarboxylase (anti-GAD) antibodies. CNS inflammation and markers of adaptive immunity have been, also, associated with some epileptic syndromes, such as West syndrome, temporal lobe epilepsy, febrile seizures, tonic-clonic seizures, and tuberous sclerosis. Inflammation and blood-brain barrier (BBB) disruption could be one of the mechanisms responsible for seizure recurrence. Recently clinical entities, characterized by severe epilepsy with a febrile, acute or sub-acute onset, sometimes associated with status epilepticus, followed by drug-resistant, partial epilepsy have been described. Some of these publications also suggested acronyms for the condition described: Acute Encephalitis with Refractory, Repetitive Partial Seizures (AERRPS) reported by Japanese authors, Devastating Epileptic Encephalopathy in School-aged Children (DESC) reported by French authors. Among children with acquired symptomatic severe epilepsy, we identified a group of previously normal children who had developed severe partial epilepsy after an acute/sub-acute illness resembling encephalitis. The etiological factors for those patients seems to remain unknown, and a possible immune-mediating or inflammatory process as pathogenesis of the disease could be hypothesized. More studies need to be addressed to finally define this peculiar epileptic entity.
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Affiliation(s)
- Nicola Specchio
- Division of Neurology, Bambino Gesù Children's Hospital, IRCCS, P.zza S. Onofrio, 4, 00165 Rome, Italy.
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Abstract
This article reviews the epidemiology of autoimmune conditions in schizophrenia, symptom manifestations of autoimmune conditions resembling schizophrenia, and the immunological changes observed in schizophrenia; and reflects on their associations with neurodevelopment, neurodegeneration, clinical course, and management of schizophrenia.
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Hanly JG, Su L, Farewell V, McCurdy G, Fougere L, Thompson K. Prospective study of neuropsychiatric events in systemic lupus erythematosus. J Rheumatol 2009; 36:1449-59. [PMID: 19447937 DOI: 10.3899/jrheum.081133] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To prospectively examine neuropsychiatric (NP) events and their association with health related quality of life (HRQOL) over time in patients with systemic lupus erythematosus (SLE). METHODS In an observational cohort study from a single academic center, NP events and their attribution were identified at enrollment and at annual assessments for up to 7 years. NP events were characterized using the American College of Rheumatology case definitions; other variables were global SLE disease activity and cumulative organ damage. The outcomes of NP events were recorded and self-report HRQOL was measured with the mental (MCS) and physical (PCS) component summary scores of the Medical Outcomes Study Short Form-36. RESULTS There were 209 patients, 88% female and 92% Caucasian, with a mean (standard deviation) age of 43.7 (13.8) years. Followup was available in 175/209 (84%) patients. There were 299 NP events in 132/209 (63%) patients over a mean followup of 3.6 (2.5) years. Thirty-one percent of NP events in 54 patients were attributed to SLE. Multivariate analysis indicated lower MCS scores in patients with NP events compared to those without events (p < 0.001) regardless of attribution. The group means for PCS scores were significantly lower in patients with NP events (p < 0.001) regardless of attribution. There was no association between HRQOL and cumulative organ damage, nor between NP events and the progression of organ damage. CONCLUSION The association of lower HRQOL with NP events over time, which is independent of progression in cumulative organ damage, emphasizes the persistent negative effect of NP events in the lives of patients with SLE.
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Affiliation(s)
- John G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia B3H 4K4, Canada.
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Raza H, Epstein SA, Pao M, Rosenstein DL. Mania: psychiatric manifestations of the antiphospholipid syndrome. PSYCHOSOMATICS 2009; 49:438-41. [PMID: 18794513 DOI: 10.1176/appi.psy.49.5.438] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is a prothrombotic condition characterized by recurrent vascular thrombosis and/or pregnancy morbidity in the presence of circulating antiphospholipid antibodies. Central nervous system (CNS) involvement is a prominent feature of APS, and many neurological manifestations have been described in published reports. There are limited data on psychiatric syndromes occurring in association with APS, and there have been no previous reports of mania associated with APS. METHOD The authors present the case of a 31-year-old man who experienced an acute manic episode in association with APS. They review the literature on psychiatric manifestations of APS, discuss potential mechanisms of CNS pathogenesis, and consider diagnostic and treatment implications of the co-occurrence of APS and psychiatric symptoms.
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Affiliation(s)
- Haniya Raza
- Department of Psychiatry, Georgetown University Hospital, Washington, DC, USA.
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Jurencák R, Fritzler M, Tyrrell P, Hiraki L, Benseler S, Silverman E. Autoantibodies in pediatric systemic lupus erythematosus: ethnic grouping, cluster analysis, and clinical correlations. J Rheumatol 2009; 36:416-21. [PMID: 19208567 DOI: 10.3899/jrheum.080588] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE (1) To evaluate the spectrum of serum autoantibodies in pediatric-onset systemic lupus erythematosus (pSLE) with a focus on ethnic differences; (2) using cluster analysis, to identify patients with similar autoantibody patterns and to determine their clinical associations. METHODS A single-center cohort study of all patients with newly diagnosed pSLE seen over an 8-year period was performed. Ethnicity, clinical, and serological data were prospectively collected from 156/169 patients (92%). The frequencies of 10 selected autoantibodies among ethnic groups were compared. Cluster analysis identified groups of patients with similar autoantibody profiles. Associations of these groups with clinical and laboratory features of pSLE were examined. RESULTS Among our 5 ethnic groups, there were differences only in the prevalence of anti-U1RNP and anti-Sm antibodies, which occurred more frequently in non-Caucasian patients (p < 0.0001, p < 0.01, respectively). Cluster analysis revealed 3 autoantibody clusters. Cluster 1 consisted of anti-dsDNA antibodies. Cluster 2 consisted of anti-dsDNA, antichromatin, antiribosomal P, anti-U1RNP, anti-Sm, anti-Ro and anti-La autoantibody. Cluster 3 consisted of anti-dsDNA, anti-RNP, and anti-Sm autoantibody. The highest proportion of Caucasians was in cluster 1 (p < 0.05), which was characterized by a mild disease with infrequent major organ involvement compared to cluster 2, which had the highest frequency of nephritis, renal failure, serositis, and hemolytic anemia, or cluster 3, which was characterized by frequent neuropsychiatric disease and nephritis. CONCLUSION We observed ethnic differences in autoantibody profiles in pSLE. Autoantibodies tended to cluster together and these clusters were associated with different clinical courses.
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Affiliation(s)
- Roman Jurencák
- Division of Rheumatology, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8
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Fragoso-Loyo H, Cabiedes J, Orozco-Narváez A, Dávila-Maldonado L, Atisha-Fregoso Y, Diamond B, Llorente L, Sánchez-Guerrero J. Serum and cerebrospinal fluid autoantibodies in patients with neuropsychiatric lupus erythematosus. Implications for diagnosis and pathogenesis. PLoS One 2008; 3:e3347. [PMID: 18836530 PMCID: PMC2556096 DOI: 10.1371/journal.pone.0003347] [Citation(s) in RCA: 137] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 09/12/2008] [Indexed: 12/25/2022] Open
Abstract
Background Despite the uncertainty in the diagnosis of neuropsychiatric involvement in systemic lupus erythematosus (SLE), attempts have been made to record the association of certain antibodies in serum with neuropsychiatric (NP) manifestations. We aimed to assess the behaviour and the association of serum and cerebrospinal fluid (CSF) autoantibodies with NP manifestations in SLE patients (NPSLE). Methodology/Principal Findings Forty-seven SLE patients, hospitalized because of NP manifestations were included. They were evaluated at hospitalization and six months later, and serum and CSF samples were obtained at each evaluation. As controls, serum samples were taken from 49 non-NPSLE patients at hospitalization and six months later; serum and CSF samples were also obtained from 6 SLE patients with septic meningitis, 16 surgical SLE patients and 25 patients without autoimmune diseases. Antinuclear, anti-dsDNA, anti-ribosomal P, Anti-N-Methyl-D-Aspartate receptor (NMDAR), anti-cardiolipin, and anti-β2 glycoprotein-I antibodies were measured. In serum, anti-ribosomal P, anti-NMDAR, and other antibodies did not differentiate among SLE groups, and the levels of all antibodies were similar among the SLE groups. Six-months later, this scenario remained unchanged and the decrease in the levels of some autoantibodies reflected a decline in disease activity, rather than a change in NPSLE. In CSF, only the presence and the levels of anti-NMDAR antibodies showed a characteristic distribution in central NPSLE and septic meningitis patients. Six months later the prevalence of most antibodies in CSF did not change, however the levels of anti-dsDNA, anti-ribosomal P, and anti-NMDAR decreased. Conclusion In NPSLE, autoantibodies in serum do not reflect their behaviour in CSF. All autoantibodies were elevated in septic meningitis reflecting the global penetration of serum antibodies into the CSF in this condition. Anti-NMDAR antibodies in CSF identified patients with central NPSLE; their continued presence in CSF 6 months after neurologic symptoms raise questions regarding the conditions under which they are pathogenic.
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MESH Headings
- Adult
- Antibodies
- Antibodies, Anticardiolipin
- Antibodies, Antinuclear
- Autoantibodies/blood
- Autoantibodies/cerebrospinal fluid
- Case-Control Studies
- Enzyme-Linked Immunosorbent Assay
- Female
- Hospitalization/statistics & numerical data
- Humans
- Immunoglobulin G
- Lupus Erythematosus, Systemic/cerebrospinal fluid
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/immunology
- Lupus Vasculitis, Central Nervous System/cerebrospinal fluid
- Lupus Vasculitis, Central Nervous System/diagnosis
- Lupus Vasculitis, Central Nervous System/etiology
- Lupus Vasculitis, Central Nervous System/immunology
- Male
- Receptors, N-Methyl-D-Aspartate/immunology
- Retrospective Studies
- Ribosomal Proteins
- Serum/immunology
- Time Factors
- beta 2-Glycoprotein I
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Affiliation(s)
- Hilda Fragoso-Loyo
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México, Distrito Federal, México
| | - Javier Cabiedes
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México, Distrito Federal, México
| | - Alejandro Orozco-Narváez
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México, Distrito Federal, México
| | - Luis Dávila-Maldonado
- Department of Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México, Distrito Federal, México
| | - Yemil Atisha-Fregoso
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México, Distrito Federal, México
| | - Betty Diamond
- The Feinstein Institute for Medical Research, Manhasset, New York, United States of America
| | - Luis Llorente
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México, Distrito Federal, México
| | - Jorge Sánchez-Guerrero
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México, Distrito Federal, México
- * E-mail:
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Affiliation(s)
- Rolando Cimaz
- AOU Meyer and University of Florence, Florence, Italy
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GOTO A, KONDO M, MINAUCHI K, KOIZUMI K, MUKAI M. Rapidly progressing central nervous system involvement despite of steroid pulse therapy in a case of systemic lupus erythematosus presented as mononeuritis multiplex. Int J Rheum Dis 2008. [DOI: 10.1111/j.1756-185x.2008.00355.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kimura M, Aramaki K, Wada T, Nishi K, Matsushita R, Iizuka N, Hashimoto A, Tanaka S, Ishikawa A, Endo H, Hirohata S. Reversible focal neurological deficits in systemic lupus erythematosus: report of 2 cases and review of the literature. J Neurol Sci 2008; 272:71-6. [PMID: 18538345 DOI: 10.1016/j.jns.2008.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 04/11/2008] [Accepted: 04/22/2008] [Indexed: 11/26/2022]
Abstract
We report two cases presenting focal neurological deficits with high intensity lesions in fluid attenuated inversion recovery (FLAIR) images on brain magnetic resonance imaging (MRI), which almost completely improved by corticosteroid therapy. Marked elevation of cerebrospinal fluid IL-6 was also noted when these patients showed neurological deficits. As far as we explored, there have been thirteen published case reports of systemic lupus erythematosus patients with reversible focal neurological deficits. The neurological symptoms varied from case to case, but could be attributed to the lesions on MRI scans. The completely reversible feature of neurological manifestations as well as MRI findings on corticosteroid therapy is distinct from any other disorder, including cerebrovascular disease and demyelinating syndrome, in the 1999 American College of Rheumatology nomenclature. Therefore, we propose that reversible focal neurological deficits should be added to the 1999 nomenclature and classification and case definitions.
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Affiliation(s)
- Miho Kimura
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa 228-8555, Japan
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Hiraki LT, Benseler SM, Tyrrell PN, Hebert D, Harvey E, Silverman ED. Clinical and laboratory characteristics and long-term outcome of pediatric systemic lupus erythematosus: a longitudinal study. J Pediatr 2008; 152:550-6. [PMID: 18346514 DOI: 10.1016/j.jpeds.2007.09.019] [Citation(s) in RCA: 213] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Revised: 07/13/2007] [Accepted: 09/10/2007] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To determine the frequency and characteristics of clinical signs, symptoms, laboratory findings, and medication use in children with pediatric systemic lupus erythematosus (pSLE) at presentation and during the course of the disease, and to examine correlations among disease manifestations, disease activity, and damage over time. STUDY DESIGN The study involved an analysis of medical records and the SLE database of an inception cohort of 256 patients with pSLE (female:male ratio, 4.7:1). RESULTS The most common clinical manifestations were arthritis (67%), malar rash (66%), nephritis (55%), and central nervous system (CNS) disease (27%). At diagnosis, patients with both renal and CNS disease had the highest SLE Disease Activity Index (SLEDAI) scores (P < .0001), but these scores were similar to those of the total group at 1 year (P = .11). Patients who developed renal and CNS disease more than 1 year after diagnosis had higher SLEDAI scores at disease onset. Some 34% of patients had Systemic Lupus International Collaborative Clinics Damage Index (SLICC-DI) scores >1 at a mean follow-up of 3.5 years. A greater proportion of patients with renal and CNS disease had SLICC-DI scores of >1, and these patients had higher mean scores compared with patients without major organ involvement (70% vs 11% [P < .0001] and 1.4 vs 0.1 [P < .0001], respectively). CONCLUSIONS Most of the patients in our cohort exhibited major organ involvement. These patients had the highest SLEDAI scores at diagnosis, which normalized at 1 year but preceded development of renal and CNS disease. The average SLICC-DI score was lower than that previously reported in patients with pSLE.
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Affiliation(s)
- Linda T Hiraki
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Abstract
Inflammation is known to participate in the mediation of a growing number of acute and chronic neurological disorders. Even so, the involvement of inflammation in the pathogenesis of epilepsy and seizure-induced brain damage has only recently been appreciated. Inflammatory processes, including activation of microglia and astrocytes and production of proinflammatory cytokines and related molecules, have been described in human epilepsy patients as well as in experimental models of epilepsy. For many decades, a functional role for brain inflammation has been implied by the effective use of anti-inflammatory treatments, such as steroids, in treating intractable pediatric epilepsy of diverse causes. Conversely, common pediatric infectious or autoimmune diseases are often accompanied by seizures during the course of illness. In addition, genetic susceptibility to inflammation correlated with an increased risk of epilepsy. Mounting evidence thus supports the hypothesis that inflammation may contribute to epileptogenesis and cause neuronal injury in epilepsy. We provide an overview of the current knowledge that implicates brain inflammation as a common predisposing factor in epilepsy, particularly childhood epilepsy.
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Affiliation(s)
- Jieun Choi
- Department of Pediatrics, Division of Neurology, Northwestern University Children's Memorial Hospital, Chicago, IL, USA
- Department of Pediatrics, Seoul National University Boramae Hospital, Seoul, Korea
| | - Sookyong Koh
- Department of Pediatrics, Division of Neurology, Northwestern University Children's Memorial Hospital, Chicago, IL, USA
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Brey RL. NEUROLOGIC MANIFESTATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS AND ANTIPHOSPHOLIPID ANTIBODY SYNDROME. Continuum (Minneap Minn) 2008. [DOI: 10.1212/01.con.0000299988.78952.d9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Avčin T, Benseler SM, Tyrrell PN, Čučnik S, Silverman ED. A followup study of antiphospholipid antibodies and associated neuropsychiatric manifestations in 137 children with systemic lupus erythematosus. ACTA ACUST UNITED AC 2008; 59:206-13. [DOI: 10.1002/art.23334] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Andrade RM, Alarcón GS, González LA, Fernández M, Apte M, Vilá LM, McGwin G, Reveille JD. Seizures in patients with systemic lupus erythematosus: data from LUMINA, a multiethnic cohort (LUMINA LIV). Ann Rheum Dis 2007; 67:829-34. [PMID: 17875548 PMCID: PMC2735413 DOI: 10.1136/ard.2007.077594] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To examine the predictors of time-to-seizure occurrence and their impact on damage accrual and mortality in LUMINA, a multiethnic (Hispanic, African American and Caucasian) cohort of patients with systemic lupus erythematosus. METHODS Seizures were defined as per the American College of Rheumatology (ARC) nomenclature and case definitions for neuropsychiatric lupus syndromes. Factors associated with time-to-seizure occurrence occurring at or after diagnosis (TD) of systemic lupus erythematosus were examined by univariable and multivariable Cox proportional hazard regression analyses. The impact of seizures on damage accrual and mortality was also examined by multivariable analyses after adjusting for variables known to affect these outcomes. RESULTS A total of 600 patients were included in these analyses. Of them, 40 (6.7%) developed seizures at or after TD; by multivariable analyses, disease activity and younger age were independent predictors of a shorter time-to-seizure occurrence (HR = 1.10 and 1.04; 95% CI 1.04 to 1.15 and 1.00 to 1.08, p = 0.0004 and 0.0304, respectively) whereas mucocutaneous involvement (HR = 0.34, 95% CI 0.16 to 0.41, p = 0.0039) and hydroxychloroquine use (HR = 0.35, 95% CI 0.15 to 0.80, p = 0.0131) were independent predictors of a longer time-to-seizure occurrence. Seizures were an independent contributor to damage accrual but not to mortality. CONCLUSIONS Seizures tend to occur early in the course of systemic lupus erythematosus, and contribute to damage accrual. Younger age and disease activity are independent predictors of a shorter time-to-seizure occurrence; antimalarials appear to have a protective role in seizure occurrence.
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Affiliation(s)
- R M Andrade
- Department of Medicine, Schools of Medicine and Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Abstract
Antiphospholipid syndrome is an important cause of neurologic morbidity. The clinical criteria for antiphospholipid syndrome include only cerebrovascular arterial and venous thrombosis, but many other neurologic manifestations have been associated with antiphospholipid antibodies (aPL). This review discusses the role of aPL in cerebrovascular manifestations and in some of the other neurologic manifestations commonly associated with these antibodies, as well as data pertaining to the pathophysiology of aPL-associated neurologic manifestations and treatment issues.
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Affiliation(s)
- Jose F Roldan
- School of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
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Zandman-Goddard G, Chapman J, Shoenfeld Y. Autoantibodies Involved in Neuropsychiatric SLE and Antiphospholipid Syndrome. Semin Arthritis Rheum 2007; 36:297-315. [PMID: 17258299 DOI: 10.1016/j.semarthrit.2006.11.003] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 10/23/2006] [Accepted: 11/23/2006] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We sought (1) to identify and (2) to define the association of all reported antibodies (Abs) with neuropsychiatric lupus (NPSLE), (3) to search for possible mechanisms that are involved in NPSLE, and (4) to determine whether we can recognize a panel of Abs associated with specific neuropsychiatric (NP) manifestations. METHODS A MEDLINE search (1975 to 2005) was performed utilizing the following terms: neuropsychiatric lupus, antiphospholipid syndrome, or central nervous system systemic lupus erythematosus matched with the term antibodies. RESULTS Twenty Abs (11 brain-specific and 9 systemic) were described in NPSLE patients. These include Abs that target brain-specific antigens (neuronal, ganglioside, synaptosomes, glia, methyl-d-aspartate receptors, lymphocytotoxic) and systemic antigens (nuclear, cytoplasmic, phospholipid, endothelial cells). Cognitive impairment, psychosis, and depression were associated with many Abs. Elevated titers of anticardiolipin Abs (aCL) were reported most often and found in patients with cognitive impairment, psychosis, depression, seizures, chorea, and migraine. No specificity was encountered among brain-specific or systemic Abs for any single NP manifestation. No studies evaluated a specific NP manifestation with the full panel of 20 Abs. A panel of brain-specific and systemic Abs may be helpful in establishing the diagnosis of NPSLE. Postulated mechanisms in experimental models included vascular occlusion and injury by pathogenic Abs in a disrupted blood brain barrier. CONCLUSIONS NPSLE is associated with brain-specific and systemic Abs. Cognitive impairment, psychosis, and depression were associated with many Abs, including aCL Abs. Possible mechanisms include vascular occlusion and injury by pathogenic Abs in a disrupted blood brain barrier.
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Affiliation(s)
- Gisele Zandman-Goddard
- Lecturer of Internal Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Israel; Head of the Department of Medicine C, Wolfson Medical Center, Holon, Israel
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Fernández Ga de Las Heras V, Gorriti MA, García-Vicuña R, Santos Ruiz JL. Psychosis leading to the diagnosis of unrecognized systemic lupus erythematosus: a case report. Rheumatol Int 2007; 27:883-5. [PMID: 17242903 DOI: 10.1007/s00296-007-0308-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Accepted: 01/02/2007] [Indexed: 10/23/2022]
Abstract
We present the case of a woman whose psychiatric clinical picture was the major manifestation of SLE with unrecognized secondary antiphospholipid syndrome. The atypical onset and the subsequent clinical course of the psychiatric manifestations led to the diagnosis. This case demonstrates the heterogeneous progress of SLE, the increasing relevance of the antiphospholipid antibodies in the central nervous system and the difficulty in making an early diagnosis.
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Abstract
The differential diagnosis, diagnostic evaluation, and treatment of late-onset chorea are reviewed. Late-onset chorea is rare and has a heterogeneous causation. A systematic approach to geriatric chorea greatly enhances a correct diagnosis. An accurate diagnosis is important because many causes of chorea are treatable or or, when heritable, may have significant implications for subsequent generations. Most late-onset chorea is either nonlimiting, requiring no treatment, has a spontaneous remission, or responds to medication. In a minority of patients, chorea is medically refractory or manifestation of an untreatable disorder.
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Affiliation(s)
- Matthew T Lorincz
- Department of Neurology, University of Michigan, 200 Zina Pitcher, 4412 Kresge III, Ann Arbor, MI 48109-0585, USA
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